Is it time to end routine catheter replacement?
As-needed replacement may be best—with careful monitoring
By Janet Colwell
Some hospitals may soon change their policies for replacing peripheral venous catheters (PVCs), thanks to recent research finding that replacement when clinically indicated is just as safe as routine replacement. Before making any changes, however, hospital leaders should draw up an actionable plan for monitoring and assessing catheters daily for signs of problems, according to experts.
At issue is a large, multicenter study, published Sept. 22, 2012 in The Lancet, showing that replacing PVCs when clinically indicated did not result in an increase in phlebitis compared with replacing them every 72 to 96 hours, the current policy at most hospitals. Switching to an “as indicated” policy could prevent many unnecessarily invasive, uncomfortable procedures for patients and could lead to huge potential cost savings, since an estimated 200 million catheters are inserted annually nationwide, the study authors wrote.
Photo by Thinkstock.
“The findings from this study are very important and may prompt individual hospitals to change policy,” said Naomi P. O’Grady, MD, an infectious disease specialist in the department of critical care medicine at the National Institutes of Health in Bethesda, Md. She noted that a clinically indicated replacement policy is consistent with current Centers for Disease Control and Prevention (CDC) guidelines on preventing intravascular catheter-related infections.
“The guidelines say that peripheral intravenous catheters do not need to be replaced more frequently than 72 to 96 hours, so if we let catheters remain in place beyond 96 hours, it is still within the guidelines,” said Dr. O’Grady, who is the guidelines' lead author. However, “if you go to an as-needed policy one could become less rigorous about changing it. You have to pay close attention to the catheter daily for signs of phlebitis,” she noted.
As such, it's best to draw up a formal policy to codify the monitoring of catheters, noted Leonard A. Mermel, DO, FACP, medical director of the epidemiology and infection control department at Rhode Island Hospital and professor of medicine at the Warren Alpert Medical School of Brown University in Providence.
“It's possible, in an ideal world, to stratify patients based on risk for how often to change a peripheral IV catheter, but practically speaking it would be difficult to do in a big busy hospital,” Dr. Mermel said. “After doing infection control at a large busy teaching hospital for a little over 20 years, I've found that it's best if you make things simple and easy to follow and have black-and-white rules of what to do.”
Need for vigilance
Replacing PVCs as clinically indicated requires that hospitals tighten up their insertion and care practices, said Mark E. Rupp, MD, FACP, professor and chief of the division of infectious diseases at the University of Nebraska Medical Center in Omaha and a co-author of the CDC guidelines.
“I'm concerned that peripheral IV catheters are sometimes inserted using less than strict aseptic conditions when it is assumed that the catheter will only be in for two or three days,” he said. “If the catheter stays in for five to seven days it is absolutely crucial that appropriate insertion procedures are carefully followed.”
That means paying close attention to using antiseptics, like chlorhexidine, when preparing the skin prior to insertion, said Dr. Rupp. In addition, dressings must be carefully applied and the site must be inspected at least daily to ensure catheters aren't becoming inflamed or infected.
An as-needed replacement policy also may foster a tendency to leave catheters in longer than really needed, said Dr. Rupp.
“The thinking may be that ‘If I don't have to change it at three to four days anymore, I'll just leave it in until the patient goes home,’” he said. “But that may not be the best thing for the patient. As soon as the IV catheter is not needed, it should be removed.”
While the Lancet study reported only one bloodstream infection among participants, it is possible that leaving catheters in longer could increase the risk for bloodstream infections over time, said Dr. Mermel, who also helped write the CDC guidelines. He noted that the average duration of therapy during the study was nearly identical in both groups—96 hours for the routine replacement group versus 98 hours for the as-needed group.
In another study co-authored by Dr. Mermel, prolonged dwell time was one factor associated with PVC-related Staphylococcus aureus infections. The study, which was published in the June 2011 Infection Control and Hospital Epidemiology, retrospectively reviewed adult patients admitted to one tertiary care hospital over a three-year period who developed staph infections. Forty-six percent of patients who developed the infections had PVC catheters left in for more than three days.
“Based on the numbers of catheters we use in our hospital, we suggested there may be as many as 10,000 PVC-related Staphylococcus aureus infections among hospitalized patients in the U.S. each year,” said Dr. Mermel. “So before we extend duration, we need to be sure it is safe in terms of risk of such infections.”
However, the authors of the Lancet study noted that bloodstream infections are initially related to insertion procedures, such as poor hand hygiene or skin preparation. As a result, they wrote, “Although routine replacement of intravenous catheters theoretically could reduce later infections, conversely it exposes the patient to the contamination risk of another insertion procedure.”
Developing a protocol
Despite the potential drawbacks, switching to an as-needed replacement policy can be worthwhile with effective planning and monitoring, experts said. They offered the following advice:
Consider using specialized teams. Specialized intravenous insertion teams have been shown to reduce risk of infections. The Lancet study authors noted that the rates of phlebitis among participants might have been lowered by the fact that 40% of the catheters used were inserted by specialized insertion teams.
Develop clear guidelines for monitoring. “Redness, warmth, tenderness, or swelling are all strong indications that the catheter needs to come out,” Dr. Rupp said. Assess catheter insertion sites regularly, every eight hours, Dr. Mermel recommended, and pay attention to any concerns expressed by the patient about pain or discomfort at the site.
Secure the site. “A lot of catheter failures may be related to inadvertent removal by the patient when he or she moves. You need to know how to secure the catheters and keep them in place as steadily as possible,” Dr. Rupp said.
Recognize when catheters aren't needed. “If a patient is not receiving IV meds and can maintain hydration status, they may not need a catheter,” Dr. Rupp said. Remove the catheter as soon as warranted—even if it's at the tail end of a patient's stay, he said.
Track your results. “It's important to carefully track whether or not leaving catheters in longer are having unintended consequences, such as an increase in bloodstream infections,” said Dr. Mermel.
Use PVCs appropriately. “One problem is use of peripheral IVs for medications in which they shouldn't be used because they are too acidic or alkaline, said Dr. Mermel. “A hospital that is trying to reduce its central line infection rate because they're publically reported may tend to overuse peripheral IVs, leading to excessive numbers of early failures due to phlebitis if used for medications that should have been administered through a central line.”
Ultimately, implementing a successful as-needed replacement policy comes down to treating the catheters with the respect they deserve, said Dr. Rupp.
“If you're going to keep them in for a longer period of time where the chances of complications increase, you need to be carefully inserting them and monitoring them closely,” he said. “But if you do those things correctly, the data suggests you can go to an as-needed policy safely and at the same time save resources and money.”
Janet Colwell is a freelance writer in Miami.
A landmark study
Following are some key facts and findings from the Sept. 22, 2012 Lancet study “Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial.”
- The multicenter, randomized, non-blinded equivalence trial recruited adults from three hospitals in Queensland, Australia, between May 20, 2008, and Sept. 9, 2009, who had intravenous catheters expected to be used longer than four days.
- Phlebitis occurred in 7% of patients when intravenous catheters were removed when clinically indicated and when they were removed routinely every three days.
- Catheter-related bloodstream infections were rare at one per 5,907 (0.02%) catheters.
- Of the 200 million catheters estimated to be inserted each year in the U.S. alone, if even 15% are needed for more than three days, then a change to clinically required replacement would prevent up to six million unnecessary intravenous catheter insertions and would save about two million hours of staff time and up to $60 million in health costs each year.
- Thirty percent of intravenous catheters had some form of failure, such as infiltration, occlusion, and accidental removal.
O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel L, et al. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52:e162-93. [PMID: 21460264]
Rickard CM, Webster J, Wallis MC, Marsh N, McGrail MR, French V, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet. 2012;380 :1066-74. [PMID: 22998716]
Trinh TT, Chan PA, Edwards O, Hollenbeck B, Huang B, Burdick N, et al. Peripheral venous catheter-related Staphylococcus aureus bacteremia. Infect Control Hosp Epidemiol. 2011;32:579-83. [PMID: 21558770] Erratum: Infect Control Hosp Epidemiol 32:735, 2011.
Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Subscribe now.
From the April 22, 2015 edition
- ACP President: SGR repeal "extraordinary and historic"
- SHEA issues guidance on contact precautions for hospital visitors
ACP Career Connection
Looking for a new hospitalist position?
ACP Career Connection can help you find your next job in hospital medicine. Search hospitalist positions nationwide that suit your criteria and preferences. Jobs are posted about two weeks before print publication of Annals of Internal Medicine, ACP Internist, and ACP Hospitalist. Exclusive “Online Direct” opportunities are updated weekly. Check us out online.
ABIM Maintenance of Certification for Hospitalists
Hospital-based internists have the option of maintaining their certification in either Internal Medicine or Internal Medicine with a Focused Practice in Hospital Medicine. Learn more about resources from ACP and the Society for Hospital Medicine to complete both MOC programs.
What will you learn from your Annals Virtual Patient?
Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.
Internal Medicine Meeting 2015 Live Simulcast!
Unable to attend the meeting this year? On Saturday, May 2, seven sessions will be streamed live from the meeting. Register for the simulcast and earn CME credit after watching each session. Watch it live or download for later viewing.